The Hickory Project Builds on the Asheville Project - An Example of Community-Based Diabetes Care Management

comparative effectiveness. The AHRQ report at page 43 concluded, “With the possible exception of the study by Koylan et al., adherence with ACEIs and ARBs was similar (Table 7).” In the second study cited by Ram and Giles, the lisinopril (ACEI) group had a higher severity of illness and greater use of concurrent medication such as antihyperlipidemics, antiplatelet agents, and beta-blockers compared with the valsartan (ARB) group, and the adjusted adherence was statistically significant but not practically significant, 89.9% for lisinopril (95% CI, 89.3%90.6%) versus 90.1% for valsartan (95% CI, 89.0-91.1%). For those who prefer trees rather than the forest, we recommend reading the 72 studies referenced in the 57-page AHRQ report on comparative effectiveness of ACEIs and ARBs and the 79 studies referenced in the 98-page NICE hypertension guideline; ACEIs and ARBs are clinically sufficiently similar to allow step therapy. Artificially limiting clinicians’ ability to care for patients by selectively citing literature should be roundly condemned by all; likewise, selectively citing contrary outlier literature to support frivolous expenditure on costly medication that fails to provide unique benefits should be also be denounced in the public forum.

comparative effectiveness. 11 The AHRQ report at page 43 concluded, "With the possible exception of the study by Koylan et al., adherence with ACEIs and ARBs was similar (Table 7)." In the second study cited by Ram and Giles, the lisinopril (ACEI) group had ahigher severity of illness and greater use of concurrent medication such as antihyperlipidemics, antiplatelet agents, and beta-blockers compared with the valsartan (ARB) group, and the adjusted adherence was statistically significant but not practically significant, 89.9% for lisinopril (95% CI, 89.3%-90.6%) versus 90.1% for valsartan (95% CI, 89.0-91.1%). 12 For those who prefer trees rather than the forest, we recommend reading the 72 studies referenced in the 57-page AHRQ report on comparative effectiveness of ACEIs and ARBs and the 79 studies referenced in the 98-page NICE hypertension guideline; ACEIs and ARBs arec linically sufficiently similar to allow step therapy.Artificially limiting clinicians' ability to carefor patients by selectively citing literatures hould be roundly condemned by all; likewise, selectively citing contraryo utlier literaturetosupport frivolous expenditureoncostly medication that fails to provide unique benefits should be also be denounced in the public forum.

Letters nn The Hickory Project Builds on the Asheville Project-An Example of Community-Based Diabetes Care Management
To the Editor: We read with interest the recent JMCP commentaryc alling for managed careo rganizations (MCOs) and community pharmacies to seize the opportunity to work together in chronic care and disease management. 1 Your readers may be interested in the HickoryP roject, ad isease management partnership developed to demonstrate the value of using community pharmacists and nurse practitioners as carem anagers to improve quality measures and positively impact patient health outcomes in Hickory, North Carolina, and the surrounding area. This combined effort includes the coordinating services of American Health Care( AHC), ap harmacy benefit manager and disease management company,a nd brings together Wells Fargo Insurance Services, community pharmacists, nurses, physicians, and support staff. One of the key functions of AHC is to integrate medical and pharmacy data for patients with diabetes who aree nrolled in the disease management program. Lessons learned from the Asheville Project, also in North Carolina, are incorporated into the HickoryProject.
Pharmacists and nurse practitioners in the local community arer ecruited and held responsible for direct patient contact (to coach, encourage, and educate the patients) with ag oal of achieving improved patient carea nd quality measures as outlined by ap atient' sp hysician and national guidelines. This project involves 9independent community pharmacies, 7nurse practitioner clinics, and AHC. Trained clinical professionals meet with each patient monthly to provide education and monitor health progress. The patient' sw eight and blood pressureare documented at each meeting, and lab values, selfmonitoring blood glucose tests, and medications arer eviewed. All interactions arer ecorded on ap atient progress summary form that is used to coordinate data between the patient and health careteam members.
The first phase of this community-based patient careproject was to organize aw orking procedureb etween AHC and the network of community pharmacists-and in some areas, nurse practitioners. The local pharmacists wererecruited and diseasespecific training sessions werep rovided. Disease-specific training was conducted through acombination of aW eb-based program and fax transmissions. Successful completion of three 2.5-hour training sessions, followed by an examination of covered materials, conferred accreditation by AHC on the pharmacist as a" HickoryP roject carem anager." The total training time for certification was approximately 9hours.
The training provided to the HickoryP roject carem anagers was conducted to update them on the latest national guidelines and protocols for diabetes management. (Six nurse practitioners involved in the HickoryProject werenot required to go through training because of their existing expertise in diabetes care management.) As of December 2006, 23 pharmacists had completed the training. An informal survey of the pharmacists revealed ah igh level of professionalism and ad esiret ob e involved in acommunity-wide effort.
The value of community pharmacists in the deliveryo f disease management programs has already been successfully demonstrated in the Asheville Project. The Asheville Project, started in 1996, is ad isease management program in which 2l arge self-employed insurers in North Carolina offer services to employees, dependents, and retirees by community pharmacists for chronic disease states such as diabetes, asthma, and depression. The Asheville Project shows that patients with diabetes who participate in this long-term pharmaceutical care program use fewer sick days and achieve lower hemoglobin A1C levels as well as improved lipid levels, while employers have experienced adecline in mean total direct medical costs. 2 Physicians working with the Asheville Project pharmacists have been pleased with the quality of patient careand have seen firsthand the benefits of ac oordinated collegial team effort in chronic disease state management. Because of monthly monitoring by the local pharmacist carem anagers, valuable physician time is saved, patient deficiencies arec orrected, and complications areaverted.
The need for quality disease management was summed up in as tatement by the National Committee for Quality Assurance: "The fact that many Americans do not receive appropriate preventive careand carefor chronic conditions like diabetes and hypertension also means that annually therea re thousands of preventable second heart attacks, kidney failures, and other conditions such as painful and debilitating fractures from osteoporosis." 3 Several recent studies demonstrate that ah andful of such conditions account for moret han half of U.S. medical costs. As reported in The State of Health CareQuality 2004,more than $9 billion is lost in productivity and nearly $2 billion is incurred in hospital costs that could be avoided through more consistent deliveryo fb est-practice care. "Moret han 14,000 heart attacks and strokes could be prevented each year through better diabetes management alone (A1C control)." 3 Fred Eckel, who reviewed the Asheville Project, stated, "Based on our Asheville experience, it is apparent to us that disease management, or health management programs as I prefer to call them, will best be accomplished through local initiatives. Eventually,r egional or national employers or payers may get into the act; but our greatest success will come through local projects." 4 To be successful, these local initiatives need to have answers to the questions regarding compensation of pharmacists for their services and "what' si ni tf or me" for patients, physicians, pharmacists, and employers.
The HickoryP roject identified prospective patients through analysis of medical and pharmacy claims, and these patients werei nvited to participate via employer information sessions and direct mailings on disease management. The patients who chose to be apart of the disease management program received reduced copayments or had copayment waiver for their management-related medications. Each patient was assigned ac are manager who provided current medical and pharmacy claims data from AHC. The carem anager was al ocal community pharmacist in most cases, and the reduced or waived copayments remained in effect for as long as the patient complied with scheduled appointments with the carem anager.P atients received disease-specific information, al ist of quality measures associated with their disease state (e.g., goals for A1C, blood pressure, and low-density lipoprotein cholesterol), and educational materials to instruct and encourage them about the importance of knowing and attaining each quality measure.
Most pharmacists would love to spend moret ime with patients, but they would quickly go out of business if they spent 15 minutes with everypatient who had achronic condition. The HickoryP roject paid $30 to the pharmacy for everyi nitial face-to-face pharmacist consultation with an enrolled patient (the sessions werea nticipated to last about 30 minutes); each 15-minute follow-up visit was compensated at the rate of $15. Analysis of the adequacy of this compensation has not yet been conducted. Patient consultations areheld in privately designated areas in the pharmacy.
New patients areassigned to the certified caremanagers, and the option of mail-order prescriptions was eliminated to facilitate moree ffective face-to-face interaction between the patient and the caremanager.Most patients in the project receive their prescriptions from their pharmacy' sc arem anagers. The care managers receive ap atient progress report each month from AHC via fax transmission that details the assigned patient' s medical and pharmacy data and any deficiencies in quality measures. (The fax transmission of information is being replaced by an online, Web-based, interactive system accessible to the caret eam members.) This monthly updated patient record follows the progression of carea nd patient assessments and is forwarded to the attending physician as aprecise recordofgoals met and goals needing improvement.
Patients also receive a" to do" list after each carem anager appointment. The carem anager talks to each patient about the importance of daily exercise, good nutritional eating habits, and the dangers of smoking; encourages the patient when it is time to see the physician; discusses needed lab tests; and reminds the patient to talk to ap hysician about specific quality measures needing attention.
The first employer group to sign on with the Hickory Project was the HickoryS prings Manufacturing Company, based in Hickory, North Carolina, and one of the nation' slargest manufacturers of furniture( with 5,910 employees). Hickory Springs Manufacturing Company implemented this program, in part, on the basis of the reported success of the Asheville Project and to evaluate the financial results and health outcomes associated with asimilar intervention for its own employees.

Baseline Measures
The following baseline findings wereg enerated from an evaluation of the beneficiaries of 3l ocal employers interested in the HickoryP roject beforep articipant enrollment in the disease management project. From medical and pharmacy data, the need for such aproject was confirmed. For the year 2005, 566 patients among these 3e mployer-sponsored groups had an International Classification of Diseases, Ninth Revision, Clinical Modification code of diabetes (250). This correlates to aprevalence of 6.1%, based on the 9,282 total covered members included in the sample. Of those diagnosed members, 509 (89.9%) were taking antidiabetic medication, which included 448 members older than 40 years. •4 9/8% of these older members (223 members) were taking some type of lipid-lowering medication •5 6.3% (252 members) weres elf-testing blood glucose (STBG) •3 2.5% (146 members) werei dentified as having had a lipid panel performed within the 1-year period prior to participant enrollment •5 0.4% (226 members) received at least 1A1C test •5 9.4% (266 members) weret aking blood pressure medications